Azathioprine as an adjuvant therapy in severe Graves’ disease: a randomized controlled open-label clinical trial

IntroductionAzathioprine (AZA) interferes with the activation of T and B lymphocytes, which are the main cells involved in the pathogenesis of Graves’ disease (GD). The aim of this study was to investigate the effectiveness of AZA as an adjuvant therapy to antithyroid drugs (ATDs) for moderate and severe GD. In addition, we conducted an incremental cost-effectiveness analysis of AZA to determine its cost-effectiveness.MethodsWe conducted a randomized, open-label, and parallel-group clinical trial. We randomized untreated hyperthyroid patients with severe GD into three groups. All patients received 45-mg carbimazole (CM) as the starting dose and propranolol 40–120 mg daily. The first group (AZA1) received an additional 1 mg/kg/day AZA, the second group (AZA2) received an additional 2 mg/kg/day AZA, and the third group (control group) received only CM and propranolol. We measured thyroid-stimulating hormone (TSH) and TSH-receptor antibody (TRAb) levels at baseline and every 3 months, while free triiodothyronine (FT3) and free thyroxine (FT4) levels were measured at the time of diagnosis, 1 month after initiation of therapy, and every 3 months thereafter until 2 years after remission. Thyroid volume (TV) was assessed by ultrasound at baseline and 1 year after remission.ResultsA total of 270 patients were included in this trial. By the end of follow-up, there was higher remission rate in the AZA1 and AZA2 groups compared with controls (87.5% and 87.5% vs. 33.4%, p = 0.002). Throughout the course of follow-up, FT3, FT4, TSH, and TRAb were significantly different between the AZA groups and the control group, but there was no significant difference regarding TV. The decline in the concentrations of FT4, FT3, and TRAb was significantly faster in the AZA2 group than in the AZA1 group. The relapse rate during the 12-month follow-up was insignificantly higher in the control group than in either the AZA1 or AZA2 group (10, 4.4, and 4.4%, p = 0.05, respectively). The median relapse time was 18 months for the control group and 24 months for the AZA1 and AZA2 groups. The incremental cost-effectiveness ratio for the AZA group compared with the conventional group was 27,220.4 Egyptian pounds per remission reduction for patients using AZA as an adjuvant for ATDs.ConclusionAZA could be a novel, affordable, cost-effective, and safe drug offering hope for patients with GD to achieve early and long-lasting medical remission.Trial registryThe trial is registered at the Pan African Clinical Trial Registry (Registration number: PACTR201912487382180)

Global overview of the management of acute cholecystitis during the COVID-19 pandemic (CHOLECOVID study)

Background: This study provides a global overview of the management of patients with acute cholecystitis during the initial phase of the COVID-19 pandemic. Methods: CHOLECOVID is an international, multicentre, observational comparative study of patients admitted to hospital with acute cholecystitis during the COVID-19 pandemic. Data on management were collected for a 2-month study interval coincident with the WHO declaration of the SARS-CoV-2 pandemic and compared with an equivalent pre-pandemic time interval. Mediation analysis examined the influence of SARS-COV-2 infection on 30-day mortality. Results: This study collected data on 9783 patients with acute cholecystitis admitted to 247 hospitals across the world. The pandemic was associated with reduced availability of surgical workforce and operating facilities globally, a significant shift to worse severity of disease, and increased use of conservative management. There was a reduction (both absolute and proportionate) in the number of patients undergoing cholecystectomy from 3095 patients (56.2 per cent) pre-pandemic to 1998 patients (46.2 per cent) during the pandemic but there was no difference in 30-day all-cause mortality after cholecystectomy comparing the pre-pandemic interval with the pandemic (13 patients (0.4 per cent) pre-pandemic to 13 patients (0.6 per cent) pandemic; P = 0.355). In mediation analysis, an admission with acute cholecystitis during the pandemic was associated with a non-significant increased risk of death (OR 1.29, 95 per cent c.i. 0.93 to 1.79, P = 0.121). Conclusion: CHOLECOVID provides a unique overview of the treatment of patients with cholecystitis across the globe during the first months of the SARS-CoV-2 pandemic. The study highlights the need for system resilience in retention of elective surgical activity. Cholecystectomy was associated with a low risk of mortality and deferral of treatment results in an increase in avoidable morbidity that represents the non-COVID cost of this pandemic

Awareness of health risks associated with energy drink consumption among students in Abha City, Saudi Arabia

Introduction Consumption of beverages, especially ones containing caffeine and other stimulants, called ‘energy drinks’, has been recognized as a growing public health problem worldwide. As energy drinks are popular among students, this study aimed to explore students’ awareness of the potential health risks associated with such drinks

Factors associated with the knowledge of obstetric danger signs among pregnant women attending primary health care antenatal care clinics in Abha city

Introduction: Knowledge of obstetric danger signs would equip women to make the right decisions and appropriate actions timely to have better health care assistance which will impose a significant impact on maternal mortality and morbidity. Hence, this study aimed to know the factors associated with the knowledge of obstetric danger signs among pregnant women who attend the primary health care clinics, which is considered as the first gate to seek health care for pregnant women during antenatal checkups. Methodology: This is a cross-sectional study conducted among 400 pregnant women selected by simple random sampling technique who were attending antenatal clinics at primary health care centers at Abha City by using an interview-based questionnaire.cores of 75% were considered to be poor, intermediate, and good scores. Frequencies and percentages were used for descriptive variables, whereas for association, tests of significance (Chi square, t-test, and F-test) were applied. Results: Almost 70.8% of participants received health information on obstetric danger signs. The main sources of information were the Internet (23%), family, relatives or friends (17%), and health care providers. The highest participants' correct responses regarding obstetric danger signs were related to severe vaginal bleeding (93.5%), convulsions (76.8%), and decreased fetal movements (76.5%). Proportions of participants with poor knowledge showed an inverse and significant increase with their educational levels (P < 0.001). The highest percentage of poor knowledge grade was observed among participants with no children (54.6%). Participants who received previous information on danger signs had significantly better knowledge grades than those who have not received previous information (P < 0.001). Conclusions: Women's knowledge was suboptimal regarding obstetric danger signs. 30% of women did not receive information about danger signs. Health education provided on obstetric danger signs to pregnant women should be enforced to those who are illiterate, are unemployed, have a low family income, and are with no or less previous pregnancies

Awareness about folic acid intake amongst Saudi women of child bearing age in the Aseer region in prevention of neural tube defects in fetus

Background: Folic acid deficiency during pregnancy can lead to critical anomalies called neural tube defects (NTDs) in fetus. Though its prevalence is low (0.5 to 2 per 1000 births) yet efforts must be made to prevent its occurrence. Thus, objective of this study was to speculate the level of awareness of folic acid intake amongst Saudi women of child bearing age in the Aseer region in prevention of NTDs and to propose measures to prevent its occurrence. Method: A descriptive cross-sectional study was carried out on 700 women of child bearing age residing in various areas of Aseer Province. A self designed questionnaire form aiming to assess the awareness of folic acid was distributed to the participants and their responses were analysed. Results: Most of the women resided in villages/small town (54.1%) and were married (66.6%), educated up to graduation level (50.9%), non working (55.4%), non smokers (97.3%) and had monthly family income of less than 5000 Saudi Riyals indicating a relatively lower economic status. Only 18% women were aware that folic acid deficiency during pregnancy could lead to NTDs. Hardly 9.1% women were aware that folic acid should be taken 3 months before the pregnancy and during first 3 months of pregnancy. At the time of study although 53.9 % of study subject women were consuming folic acid supplements because of pregnancy, however 51.3 % women expressed their unwillingness to do so in future if they ever conceived. Conclusion: Awareness about folic acid intake amongst Saudi women of child bearing age in the Aseer region in prevention of NTDs in fetus was found to be low. Therefore formulating better health education strategies, support from healthcare staff, strengthening health care programs and frequent health visits/surveys are the proposed measures to ensure a higher level of awareness on the issue

Global overview of the management of acute cholecystitis during the COVID-19 pandemic (CHOLECOVID study)

Background: This study provides a global overview of the management of patients with acute cholecystitis during the initial phase of the COVID-19 pandemic. Methods: CHOLECOVID is an international, multicentre, observational comparative study of patients admitted to hospital with acute cholecystitis during the COVID-19 pandemic. Data on management were collected for a 2-month study interval coincident with the WHO declaration of the SARS-CoV-2 pandemic and compared with an equivalent pre-pandemic time interval. Mediation analysis examined the influence of SARS-COV-2 infection on 30-day mortality. Results: This study collected data on 9783 patients with acute cholecystitis admitted to 247 hospitals across the world. The pandemic was associated with reduced availability of surgical workforce and operating facilities globally, a significant shift to worse severity of disease, and increased use of conservative management. There was a reduction (both absolute and proportionate) in the number of patients undergoing cholecystectomy from 3095 patients (56.2 per cent) pre-pandemic to 1998 patients (46.2 per cent) during the pandemic but there was no difference in 30-day all-cause mortality after cholecystectomy comparing the pre-pandemic interval with the pandemic (13 patients (0.4 per cent) pre-pandemic to 13 patients (0.6 per cent) pandemic; P = 0.355). In mediation analysis, an admission with acute cholecystitis during the pandemic was associated with a non-significant increased risk of death (OR 1.29, 95 per cent c.i. 0.93 to 1.79, P = 0.121). Conclusion: CHOLECOVID provides a unique overview of the treatment of patients with cholecystitis across the globe during the first months of the SARS-CoV-2 pandemic. The study highlights the need for system resilience in retention of elective surgical activity. Cholecystectomy was associated with a low risk of mortality and deferral of treatment results in an increase in avoidable morbidity that represents the non-COVID cost of this pandemic